Instructions
Answer questions as they relate to you. For most answers, check the boxes most applicable to you or fill in the blanks.
1.
Your Name:
2.
Why do you have your students participate in this Service Learning Volunteer Opportunity?
(Select all that apply.)
To enhance learning in my school class
Required service hours for school
For senior/culminating/capstone project
Environment
Human Services
Public Safety
Education
Homeland Security
Fun or personal interest
For interest projects, badges, achievement awards in scouts, 4H, YMCA, for example.
Career/Job interest and experience
Community involvement
3.
Name of class
4.
Name of Youth Organization
5.
Address
6.
Zip Code
7.
Name of Adult Leader or Contact
If teaching at an educational institution, complete the following
8.
School (K-12, College, or University) Name
9.
School District
10.
Do you have a service hour requirement for graduation?
Yes
No
11.
E-Mail Address
12.
Gender
Male
Female
13.
How do you describe yourself?
Caucasian/White
Asian-American
African-American/Black
Native-American
Hispanic/Latino/a
Other:
14.
Have you ever included service learning in your instruction before this time?
15.
Where do you get news about possible service project options in your community, city, world?
Television
Radio Stations
Newspaper
Internet
Friends
Check all that apply for this project
16.
Communication (2008)
Public speaking skills
Writing
Interpersonal communication
Working in a team
17.
Quantitative and Scientific Reasoning (2009)
ID problem
Research/evaluate solutions
Data collection and analysis
Implement solutions
18.
Democracy, Diversity, and Community Stewardship (2010)
Project issue laws and policy
Builds tolerance and appreciation of racial, ethnic, economic, environmental, and other areas of diversity.
Democratic process: dialogue for information and discussion leading to decision making.
Project issue advocacy
19.
Other
Career Awareness and Life Skills (2011)
The Arts (2012)
20.
Essential Question/Issue of this service learning project
(for example: increased sufficiency, motivation, connection to school, life, etc)
1 = least impact
2
3
4
5 = greatest impact
21.
How much did this service learning project change/impact your life?
22.
How much did this service learning project influence or change the life of the service recipient?
23.
How much did this service learning project influence or change the life of the community?
(Please answer the following questions and provide any other comments you desire)
24.
From your perspective, what were the outcomes of this project for all involved?
25.
How well did the student achieve the learning goals you set at the outset of this project?
26.
Would you change this project in the future? If so, how?
27.
What suggestions to increase this project's success, do you have for the community agency where this project was completed?
28.
Seniors
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